Stroke-Certified Centers Have Better Early Survival Rates

All these damned statistics and they still tell you nothing useful. No way to use this to compare which hospital to go to. What would be even more useful would be the disability rate and severity of stroke for each hospital.
http://www.medpagetoday.com/Cardiology/Strokes/59332?xid=nl_mpt_cardiodaily_2016-07-27&eun=g424561d0r

• by Kristin Jenkins
  Contributing Writer, MedPage Today

• This article is a collaboration between MedPage Today® and:
  

Action Points

• Note that this study of Medicare administrative data found improved survival when patients with ischemic stroke were treated at a Primary Stroke Center.
• Be aware that assumptions in the data (such as the use of zip code centroids as home location) could have subtly biased these results.

Sending stroke patients to a primary stroke center (PSC) for specialized treatment was associated with better early survival than at noncertified hospitals, a retrospective cohort study showed.
The study revealed that admission to PSCs -- centers certified by The Joint Commission to ensure adherence to guidelines and efficient delivery of disease-specific care -- was associated with 1.8% (95% CI −2.1% to −1.4%) lower 7-day and 1.8% (95% CI −2.3% to −1.4%) lower 30-day case fatality.
However, travelling 60 minutes to a PSC offset the 7-day survival advantage, Kimon Bekelis, MD, of Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and colleagues reported online in JAMA Internal Medicine.
Similarly, if the 'drip and ship' trip took longer than 90 minutes, the travel time offset the 30-day survival advantage, according to researchers.
"These results are statistically significant and are clinically significant, implying one life saved for every 56 treated in a PSC," the researchers wrote.
"With the current distribution of PSCs, 16.4% of patients are located at least 90 minutes by ground transportation from the nearest PSC," they noted. "Further investigations are necessary to identify the best combination of approaches to improve access to centers of excellence and stroke outcomes."
Sending patients via air could get almost all patients to a PSC on time, the researchers suggested. Expanding telemedicine applications, upgrading smaller hospitals into Acute Stroke-Ready Hospitals, and creating a broader hospital network could also improve access to specialized stroke care, they said.
But improving stroke survival by getting patients to a specialized treatment center in the first 90 minutes only works for patients eligible for reperfusion therapy and those with hemorrhagic stroke requiring immediate clot evacuation or ventriculostomy, Lee H. Schwamm, MD, of the Stroke Service at Massachusetts General Hospital, Harvard Medical School, Boston, said in an accompanying editorial.
Hemorrhagic stroke carries with it less diagnostic uncertainty, a greater likelihood of transfer, but also greater mortality than ischemic stroke. Relatively few patients with hemorrhagic stroke have a dramatically altered outcome despite treatment in the "golden hour," he pointed out.
"Until we have data from randomized trials of pre-hospital triage, it is unlikely given the prevalence of stroke that we will find a more refined and pragmatic recommendation than the following: if it is a disabling stroke that started in the last 6 hours, then go to the highest-level stroke center that is within 30 to 45 extra minutes of drive time," Schwamm wrote. "However, because many hospitals with the highest levels of stroke resources are urban medical centers struggling to manage their annual increases in ED volume, this approach to sorting may increase competing risks to patient outcome."
When large-vessel occlusion is suspected and the patient re-routing mechanism kicks into high gear, "let us make sure that the destination of interest can deliver the goods," Schwamm added. "In the words of Albus Dumbledore, 'We must all face the choice between what is right, and what is easy. ...'"
For "smart triage," what's needed is a unified stroke care system that brings together centers that report performance data, Schwamm suggested. "Stroke incidence and 90-day functional outcomes should become a reportable disease so that meaningful data can be collected on all patients with stroke," he said.
Smartphone apps could determine the best possible destination for each patient, factoring in crucial data such as the stroke onset time, severity, travel times, hospital door-to-needle and door-to-puncture times, re-canalization success rates, and in-hospital mortality.
"Such a prehospital system should adhere to national standards but be customized to reflect the local resources, prevalence of stroke, best available screening tools, acceptable levels of erroneous triage, and competing costs of the additional transport and reduced EMS availability," Schwann said. "It will not be easy, but it is well worth doing."
The study looked at 865,184 Medicare beneficiaries seen with a stroke from Jan. 1, 2010, to Dec. 31, 2013. Mean age was 78.9 years and 55.5% were female.
More than half of the cohort (53.9%) was treated at one of 976 PSCs in the nation. Drive times were calculated based on zip code centroids and StreetMap North America was used to calculate the optimal travel time routes.
Although researchers had no information on where the patient was at the time of the stroke, the Framingham Study has demonstrated that most strokes happen at home, so they used population-weighted zip code points to represent patient origins.
Almost one-quarter of patients lived closer to a PSC than to a non-PSC institution. The review showed that patients admitted to a PSC were more likely to receive IV tissue plasminogen activator (6.0% versus 2.8%) or undergo mechanical thrombectomy (1.0% versus 0.2%) for ischemic stroke compared with their counterparts taken to non-PSC institutions.
The review also showed that differential travel time was a strong factor in PSC admission. A total of 87.5% of patients were admitted to a PSC when it was at least 1 hour closer than the nearest non-PSC institution. On the other hand, only 38.8% of patients were admitted to a PSC when it was 1 hour farther from the non-PSC institution.
"We did not find evidence that those who lived nearest to a PSC were sicker than those living far from a PSC: predicted mortality in the former was 15.8%, while that in the latter was 15.7%" (P=0.57), Bekelis and colleagues said.
Receiving treatment in a PSC was associated with a 30-day survival benefit for patients who travelled for:

• 20 minutes (adjusted difference 2.7%, 95% CI 1.5%-3.9%)
• 20 to 39 minutes (AD 1.8%, 95% CI 1.3%-2.2%)
• 40 to 59 minutes (AD 2.6%, 95% CI 0.7%-2.8%)
• 60 to 89 minutes (AD 1.7%, 95% CI 0.2%-2.4%)

The study had a number of limitations, the researchers acknowledged, including residual confounding caused by differences in time from stroke onset as well as the fact that stroke severity was unmeasured in the Medicare claims data. In addition, assigning populations to zip code centroids may have given falsely low travel times for some patients while overestimating travel times for others, they said.